Ghost Victories – an excerpt from Upstream by Dan Heath

Amazon affiliate link to book listing for Upstream by Dan Heath
The link to the image takes you to the Amazon listing for the book. If you happen to order it, I get a small kickback, no cost to you, Just FYI.

Dan Heath has just published a new book, Upstream: The Quest to Solve Problems Before They Happen.

I just got the book, and am reading it now. I think there is going to be a lot of good material to discuss here.

But this post is about a marketing email with an excerpt really resonated with me, and I want to discuss that. I wrote to Dan Heath, and got his permission to use pieces of the excerpt here. (Thank you, Dan)

Management By Measurement = “Ghost Victories”

I have talked about what I call “management by measurement” in the past. In that post I told a true story of a company that placed very heavy emphasis on reducing inventory levels without digging into how that performance was achieved. The net result was a an embarrassed CEO during a quarterly analyst’s call. Not good.

Dan Heath talks about the same thing in Upstream. He calls it “ghost victories.”

[when] there is a separation between (a) the way we’re measuring success and (b) the actual results we want to see in the world, we run the risk of a “ghost victory”: a superficial success that cloaks failure.

The most destructive form of ghost victory is when your measures become the mission. Because, in those situations, it’s possible to ace your measures while undermining your mission.

He goes on to describe a case in the U.K. where the Department of Health established penalties for wait times longer than four hours in the Emergency Departments. And it worked. Wait times were reduced – at least on paper. Then the facts began to emerge:

 In some hospitals, patients had been left in ambulances parked outside the hospital—up until the point when the staffers believed they could be seen within the prescribed four-hour window. Then they wheeled the patients inside.

In the old post I referenced above, I said:

If making the numbers (or the sky) look good is all that matters, the numbers will look good. As my friend Skip puts it so well, this can be done in one of three ways:

  • Distort the numbers.
  • Distort the process.
  • Change the process (to deliver better results).

The third option is a lot harder than the other two. But it is the only one that works in the long haul.

All of this ties very well to Billy Taylor’s keynote at KataCon6 where he talked about the difference between “Key Activities” and “Key Indicators.” It is only when we can get down to the observable actions and understand the cause-and-effect relationship between those actions and the needle we are trying to move that we will have any effect.

To avoid the “Ghost Victory” trap, Dan recommends “pre-gaming” your metrics and thinking of all of the ways it would be possible to hit the numbers while simultaneously damaging the organization. In other words, get ahead of the problem and solve it before it happens.

He proposes three tests which force us to apply different assumptions to our thinking.

The lazy bureaucrat test

Imagine the easiest possible way to hit the numbers – with the least amount of change to the status quo. The story I cited above about inventory levels is a great example.

I can make my defect rates improve by altering the definition of “defect.”

There are lots of accounting games that can be played.

This is one to borrow from Skip’s list – How can the underlying numbers be distorted to make this one look good when it really isn’t?

The “rising tides” test

What external factors would have a significant impact on this metric? For example, I was working at a large company where a significant part of their product cost was a commodity raw material. As the market price went down, “costs” went down, and bonuses all around. But when the market price went up, “costs” went up and careers were threatened and bad reviews issued.

Those shifts in commodity prices had nothing to do with how those managers were doing their jobs, the tide rose and fell, and their fortunes with it.

The question in my mind is “What things would make this number look good, or bad, without any effort or change in the process we are trying to measure?”

The defiling-the-mission test

Hmmm. This is a tough one. (not really)

And it is a really common problem in our world of quarterly and annual expectations. In what ways could meeting these numbers in the short term ultimately hurt our reputation, our business, in the long term?

For example, I can think of an ongoing story of a product development project that hit its cost and schedule milestones (what was being measured). But they did so at the cost of destroying their reputation with customers, their Federal regulators and the public (and, to a large extent, their employees). They now have a new CEO, but the deeper problem has origins in the late 1990s.

How long will it take them to recover? That story is still playing out.

In another case I was in a meeting with a team that was discussing a customer complaint. The ultimate cause was a decision to substitute a cheaper material to reduce production costs. But this is a premium brand. There was a great question asked there: “Which of our values did we violate here?” – so the introspection was awesome.

Next step? Ask that question before the decision is made: “Is this decision consistent with our values?” If that makes you uncomfortable, then time to look in the mirror.

Then there is this little incident from 2010:

Picture of burning Deepwater Horizon oil platform
BP Deepwater Horizon fire – Photo by USCG

The metric was cost and schedule. Which makes sense. But the behavior that was driven was cutting corners on safety.

Getting Ahead of Problems

The book’s subtitle says it is about getting ahead of problems. I am looking forward to reading it and writing something more comprehensive.

KataCon 2020: Billy Taylor on Leadership

Photo by Michele Bucher / Lean Frontiers

Continuing my breakdown of Billy Taylor’s opening keynote at KataCon…

Key Bullet Points

  • People follow what you do before they follow what you say.
  • If you (as a leader) think you are above the process…
  • Deliberate practice on your practice of leadership. Focus on one thing.
  • Break down your leadership style [into elements]. Practice deliberately on one thing you want to reinforce or improve.

That second bullet is a real challenge for those of us who are in leadership positions (or even positions of influence). “If you think you are above the process…” – do you follow the standards and expectations you ask of others?

I think a good test would be “If a production worker corrected you, how would you respond?” If your internal emotional response (that initial feeling you have, not how you show yourself) is anything other than “Thank you for reminding me” then you are exempting yourself from the rules.

The other take-away:

Throughout his presentation, Billy was tying together the idea of “deliberate practice” and “developing leadership skills.” Leadership is a process, and processes can be broken down into their constituent elements and practiced.

This ties back perfectly to a broad spectrum of leadership development models. In the end, what we can control are:

  • What we say.
  • How we say it.
  • Who we say it to.
  • The structure of the environment that either inhibits or encourages the behaviors we want.

All of these things can be developed through experimentation, and then practiced. This is what Toyota Kata is about.

What Is Your Target Story?

One of the artifacts of Extreme Programming as practiced by Menlo Innovations is the Story Card. In the purest sense, a story card represents one unit of work that must be done by the developers to advance the work on the software project.

But the content and structure of the story card make it much more powerful than a simple task assignment. The story card is written in a way that engages the programming pair doing the work.

Before a story card is created the team works very hard to identify the primary persona that represents the human being who most benefits from their work. That persona gets a name, a face, a biography. She has wants, needs and aspirations.

Menlo primary persona
(c) Menlo Innovations. The primary persona is shown in the center of the target. There are two shown in the second ring, and three in the third ring.

Why? A couple of reasons.

First, it establishes priority of effort. In software development compromises must be made between optimizing the interface and workflows for various users. By identifying the primary persona, the team says “This person’s use of the software will be optimized.” Other users will certainly be accommodated, but any compromise will break in favor of the primary persona.

Menlo, for one, works very hard in the up-front design process to smoothly integrate the workflow created by their software into the larger context and workflow that their end-user is trying to carry out.

The other effect is more subtle. It humanizes the “user” as the developers are talking about what their code does, or does not, do.

Rather than simply set out a feature in an abstract way, the story card focuses on granting an ability to the main persona. The process of creating the personas, and developing the persona map humanizes the group of people that would traditionally be thought of as “the users.”*

Thus, the feature would be described something like this:

“Sara is able to select her choice of color from a pull-down menu of options.”

Then the developers write code that enables Sara to do this, quickly and easily.

This is a simplification, but it suffices to set up my main point.

Who Are You Optimizing Your Improvements For?

Let’s translate this thinking into our world of continuous improvement.

Who is your key persona? Who are you enabling with your process improvement? What will this person be able to do that, today, he cannot?

Rather than saying “The lowest repeatable time does not exceed 38 seconds” as a target condition, what if I said “John is able to routinely perform the work in 38 seconds when it is problem-free.”

I don’t know about you, but I feel a lot more emotionally engaged with the second phrasing. This is doubly true if John is an actual person actually doing the work.

What about scaling to other shifts, other operators?

Yup. I agree that at some point your target condition is going to shift to “Any trained team member” but what I tell people today when they are trying to go there first is this:

“If you can’t get it stable with one person, you are never going to get there with multiple people.”

You have to get it to work once first. Then introduce the next layer of complexity. Start simple. One step at a time. Control your variables.

I have been experimenting with this linguistic shift in my Toyota Kata classes and consulting.

If you are in R&D this is an even more direct application back to Menlo’s model.

Training = Giving People Ability

I also ran an experiment with a client HR team that was charged with developing a comprehensive on-boarding training process.

Rather than do the traditional thing, which is take the laundry list of topics they are supposed to try to cover, and trying to figure out how to stuff everything into the time they have been given (40 hours, which is really more like 35 hours), I asked them to experiment with the following:

For each skill they have been asked to train, write it on a separate 5×7 card in the form of “[The learner] is able to _________.” In other words, describe the skill as an ability that someone is able to demonstrate.

Then determine how they will test that skill. Do that before they even think about how they are going to teach it.

Then develop training experiences and exercises that they believe will allow the learner to pass the test.

Software developers will recognize this as “test driven development” – start with the unit test, then write the code.

Testing Your Target Condition

As in the example above, a target condition should also be testable. By stating what we will observe or measure when the target condition is met, we are constructing a “unit test” of sorts.

By stating what we will observe or measure first, we can separate “solved” from “the solution” and open up the possibilities of what solution(s) we will experiment with.

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In the culture of many more traditional software development and I.T. organizations, “users” can be almost a derogatory term, with an implied, usually (but not always) silent “dumb” appended to the front. We write Books for Dummies so they can understand our brilliant systems.

The Cancer of Fear

File:Nandu River Iron Bridge corrosion - 03.jpg

I am sitting in on a daily production status meeting. The site has been in trouble meeting its schedule, and the division president is on the call.

The fact that a shipment of material hadn’t been loaded onto the truck to an outside process is brought up. The actual consequence was a small delay, with no impact on production.

The problem was brought up because bringing up process misses is how we learn what we need to work on.

The division president, taking the problem out of context, snaps and questions the competence of the entire organization. The room goes quiet, a few words are spoken in an attempt to just smooth over the current awkwardness. The call ends.

The conversation among those managers for the rest of that day, and the next, was more around how to carefully phrase what they say in the meeting, and less about how do we surface and solve problems.

This is understandable. The division president clearly didn’t want to hear about problems, failures, or the like. He expected perfect execution, and likely believed that by making that expectation loud and clear that he would get perfect execution.

That approach, in turn, now has an effect on every decision as the managers concern themselves with how things will look to the division president.

Problems are being discussed in hallways, in side conversations, but not written down. All of this is a unconscious but focused effort to present the illusion that things are progressing according to plan.

Asking for help? An admission of failure or incompetence.

This, of course, gets reflected in the conversations throughout the organization. At lower levels, problems are worked around, things are improvised, and things accumulate and fester until they cannot be ignored.

They the bubble up to the next level, and another layer of paint is plastered over the corrosion.

Until something breaks. And everyone is surprised – why didn’t you say anything? Because you didn’t want us to!

In a completely different organization, there were pre-meetings before the meeting with the chief of engineering. The purpose of these pre-meetings was to control what things would be brought up, and how they would be brought up.

The staff was concealing information from the boss because snap reaction decisions were derailing the effort to advance the project.

And in yet another organization they are getting long lists of “initiatives” from multiple senior people at the overseas corporate level. Time is being spent debating about whether a particular improvement should be credited to this-or-that scope. It this a “value improvement,” is it a “quality improvement,” is it a “continuous improvement” project?

Why? Because these senior level executives are competing with one another for how much “savings” they can show.

Result at the working level? People are so overwhelmed that they get much less done… and the site leader is accused of “not being committed” to this-or-that program because he is trying to juggle his list of 204 mandated improvement projects and manage the work of the half-a-dozen site people who are on the hook to get it all done.

And one final case study – an organization where the site leader berates people, directly calls them incompetent, diminishes their value… “I don’t know what you do all day”, one-ups any hint of expert opinion with some version of “I already know all of that better than you possibly could.”

In response? Well, I think it actually is fostering the staff to unite as a tight team, but perhaps not for the reasons he expects. They are working to support each other emotionally as well as running the plant as they know it should be run in spite of this behavior.

He is getting the response he expects – people are not offering thoughts (other than his) for improvements, though they are experimenting in stealth mode in a sort of continuous improvement underground.

And people are sending out resumes and talking to recruiters.

This is all the metastasized result of the cancer of fear.

Five Characteristics of Fear Based Leaders

Back in 2015 Liz Ryan wrote a piece in Forbes online called The Five Characteristics of Fear Based Leaders.

In her intro, Liz Ryan sets out her working hypothesis:

I don’t believe there’s a manager anywhere who would say “I manage my team through fear.”

They have no idea that they are fear-based managers — and no one around them will tell them the truth!

And I think, for the most part, this is true. If I type “how to lead with fear” into Google I get, not surprisingly, no hits that describe the importance of intimidation for a good leader – though there are clearly leaders (as my example above) who overtly say that intimidation is something they do.)

My interpretation of her baseline would be summarized:

People who use fear and intimidation from a position of authority are often tying their own self-esteem to their position within that bureaucratic structure. Their behavior extends from their need to reinforce their externally granted power, as they have very little power that comes from within them.

They are, themselves, afraid of being revealed as unqualified, or making mistakes, or uncertain, or needing help or advice.

I have probably extended a bit of my own feelings into this, but it is my take-away.

She then goes on to outline five characteristic behaviors she sees in these “leaders.” I’ll let you read the article and see if anything resonates.

Liz Ryan’s article is, I think, about how to spot these leaders and avoid taking jobs working for them.

This post is about how the organization responds to fear based leadership.

The Breakdown of Trust

A long time ago, I wrote a post about :The 3 Elements of “Safety First”. Today I would probably do a better and more nuanced job expressing myself, but here is my key point:

If a team member does not feel safe from emotional or professional repercussions, it means they do not trust you.

Fear based leadership systematically breaks down trust, which chokes off the truth from every conversation.

Here is my question: Do you want people to hide the truth?

If the answer is “No,” then the next question is “What forces in your organization encourage them to do so?” because:

Your organization is PERFECTLY designed to produce the BEHAVIORS you are currently experiencing.

– VitalSmarts via Rich Sheridan

LEI Book: Getting Home

“Are you ahead or behind?” seems an innocent enough question.

But when asked by a Toyota advisor, the simple process of becoming able to answer it launched Liz McCartney and Jack Rosenburg on a journey of finding consistency in things that were “never the same” and stability in things that “always changed.”

Getting Home is, first and foremost, a story. And, with the “business novel” being an almost worn-out genre, seeing a non-fiction story was refreshing. So when Chet Marchwinski from the LEI offered a review copy to me, I accepted.

For the story background, I’ll leave it to you to read the blurb on Amazon.* Better yet – read the book – and it is worth reading. I’ll say that right up front.

Yet with stories like this it is all too easy to dismiss them because they have different circumstances from “my” specific case and say “Yeah, it worked there, but won’t work here.”

I would contend, however, that in this case “it worked” in situations that are far more difficult than anything we are likely to encounter in most organizations.

What I want to do here is help pull their specific achievements into more general application – what lessons are here that anyone can take away and apply directly.

What They Achieved

I can’t think of a lot (any?) business circumstances that would have more built-in variability and sources of chaos than the process of rebuilding communities after a disaster such as a hurricane or flood.

Every client has different circumstances. The make, mix and skill levels of the volunteer workforce changes continuously. Every community has different bureaucratic processes – not to mention the various U.S. government agencies which can be, well, unpredictable in how and when they respond.

Yet they have to mobilize quickly, and build houses. This means securing funding, getting permits, mobilizing unskilled and skilled labor, and orchestrating everything to meet the specific needs of specific clients on a massive scale… fast.

How They Achieved It

When they first connected with their Toyota advisor, the simple question, “Are you ahead or behind?” prompted the response that drives all improvement, all scientific advancement, all innovation:

“We don’t actually know.”

Actually they did, kind of, but it was in very general, high-level terms.

And that is what I encounter everywhere. People have a sense of ahead or behind (usually behind), but they don’t have a firm grasp on the cause and effect relationship – what specific event triggered the first delay?

This little book drives home the cascading effect of ever deepening understanding that emerges from that vital shift from accepting things as they are to a mindset of incessant curiosity.

Being able to answer “Are you ahead or behind?” means you have to have a point of reference – what is supposed to happen, in what order, with what timing, with what result. If you don’t know those things, you can only get a general sense of “on track” or not.

They had to develop standards for training – what to train, how to train – volunteers! – , which meant challenging assumptions about what could, and could not, be “standardized.” (A lot more than you think.)

A standard, in turn, provides a point of reference – are we following it, or are we being pushed off it. That point of reference comes back to being able to know “Are we ahead or behind?”

 

It Isn’t About the Specific Tools

Yet it is. While it isn’t that important about whether this-or-that specific tool or approach is put into place, it is critical to understand what the tools you use are there to achieve.

As you read the book, look for some common underlying themes:

Information as a Social Lever

The project started revolving around the ahead/behind board.

In the “lean” world, we talk about “visual controls” a lot, and are generally fans of status boards on the wall. We see the same thing in agile project management (when it is done well).

These information radiators work to create conversations between people. If they aren’t creating those conversations, then they aren’t working. In Getting Home it was those conversations that resulted in challenging their assumptions.

Beyond Rote Implementation

Each tool surfaced more detail, which in turn, challenged the next level. This goes far beyond a checklist of tools to implement. Each technical change you make – each tool you try to put into place – is going to surface something that invites you to be curious.

It is the “Huh… what is happening here?” – the curiosity response – that actually makes continuous improvement happen. It isn’t the tools, it is the process of responding to what they reveal that is important.

Summary

Like the tools it describes, Getting Home is an invitation, and that is all, to think a little deeper than the surface telling of the story.

My challenge to you: If you choose to read this book (and I hope you do), go deeper. Parse it. Ask “What did they learn?” ask “What did this tool or question reveal to them, about them?” And then ask “What signals did they see that am I missing in my own organization?”

 

 

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*This is an affiliate link that give me a very small kickback if you happen to purchase the book – no cost to you.

How Do You Know They Know?

TWI Job Instruction is built around a four step process titled “How to Instruct.”

image

Steps 2 and 3 are the core of the process.

  • Present the Operation
  • Try Out Performance

I want to discuss Step 3: Try Out Performance

Teaching Back as Learning

All too often I see “training” that looks like this:

  • Bring the team members into a room.
  • Read through the new procedure – or maybe even show some PowerPoints of the procedure.
  • Have them sign something that says they acknowledge they have been “trained.”

This places the burden of understanding upon the listener.

The TWI model reverses this paradigm with the mantra at the bottom of the pocket card which, though they vary from version to version, is some form of: If the student hasn’t learned, the teacher hasn’t taught.

Having the learner teach back to the instructor does two things:

  1. The learner has to understand it better to be able to explain it.
  2. It provides a verification check that the instruction has been effective.

Point two is important here. Instruction is a hypothesis: “If I teach these steps, in this way, my learner will be able to perform the process.”

Having them teach back is the testable outcome of this hypothesis. If the the learner struggles, then the instructor must re-instruct. But not simply by rewinding the script and playing it again… we know that didn’t work. Instead the instructor now has to get curious about which points are confusing the learner and why, and correct his instruction.

But that’s not what I came here to discuss. TWI is just a lead-in.

Learning to See – by Practicing

An operations manager who is learning fast was challenging my insistence on having a visual status board that showed the real-time location of product on the line.

In the same breath, he was saying that he wanted the leads and the supervisor to be able to “walk the trapline” and do better seeing issues coming before a train wreck. (Empty positions, overproduction, etc.)

My response was “Having them update the magnets on that board every time something moves forces them to practice seeing what is where.”

In other words, by making them teach you where things are, and demonstrate their knowledge, they have to learn how to see that bigger picture.

“That’s the best explanation I have ever heard.”

The operations manager can walk the line and see the status himself. He doesn’t need the board. In fact, he could see even better if he went up the mezzanine overlooking the line. It’s all there.

But the board isn’t for his benefit. It is a learning tool. It is structure for the leads and supervisors to have a joint conversation, facing the board instead of each other, and reach agreement about what is where.

It gives them a clear indication if they need to escalate a problem, and a way to be able to converse about when and how they might recover (or not).

In other words, it is “Grasp the Current Condition” continuously, in real time. This lets them compare the current condition with the target condition – the standard depicted on the board.

By seeing gaps quickly, they have a better chance at seeing what obstacle or problem prevented them from operating to the target.

That, in turn, gives the manager an opportunity – in invitation – to shape the conversation into one about improvement.

Back to Job Instruction

This is exactly the same process structure as having the learner demonstrate performance. It is a check, right after the operation (present the operation) was performed to see how well it worked.

Fine Grained Observation

All of this is about moving observations, evaluations, checks, verifications away from batching them at the end of a huge block of work and embedding them into one-by-one flow. It builds Ohno’s “chalk circle” into the work itself.

If You Think “We Can’t Please Our Customers” You’ll Be Right

The center of the B Concourse at O’Hare Airport in Chicago is dominated by a Brachiosaur skeleton, part of the Field Museum exhibit for their store there.

IMG_20131206_215236_938

As a reminder for those of you over the age of 14, the Brachiosaurus was 70 feet long, 30 feet tall, weighed in at around 60 tons.* It had a brain the size of an avocado. It wasn’t smart. It wasn’t fast. Its main defense against predators was that it was simply too big to catch and eat.

In the shadow of the Brachiosaurus is United Airlines’ main customer service desk for their headquarters hub.

Back in June, Chris Matyszczyk published some really interesting commentary on Inc. Magazine’s site: The CEO of United Airlines Says He Can’t Really Make Passengers Happy

In his article, he quotes from an interview Oscar Munoz, the CEO of United Airlines, gave to ABC. From the interview:

“It’s become so stressful,” he said, “from when you leave, wherever you live, to get into traffic, to find a parking spot, to get through security.”

“Frankly,” Munoz added, “by the time you sit on one of our aircraft … you’re just pissed at the world,” and improving the flying experience won’t ultimately depend on “what coffee or cookie I give you.”

My interpretation? “We have given up trying to please our customers.”

That was the interpretation of Ed Bastian, Munoz’s counterpart at Delta Airlines:

…when Munoz’s views were put to Delta CEO Ed Bastian by Marketplace.

His response was, well, quite direct:

“I disagree. Those certainly aren’t Delta customers he is speaking to.”

My Perspective as a Frequent Flyer

Just so you know my perspective: In the course of my work, I typically purchase between 10 and 20 thousand dollars worth of airfare a year. While this isn’t anywhere near the highest, I think I am the kind of customer an airline wants to get and retain.

Further, I know the system. I know what to expect, can quickly distinguish “abnormal” from “normal” and know how to maneuver to get out in front of issues I see developing. I pay attention to weather and other events that might disrupt the system, and contingency plan accordingly. I know, generally, how to arrange my stuff to get through TSA smoothly (though they can be arbitrary).

And I have the perks of a heavy frequent flier, which buffers me from a lot of the “stuff” that casual travelers have to contend with.

Munoz used some words that really identify the problem: …by the time you sit in one of our aircraft…”

This casual statement, which correlates with my experience as a former United Airlines customer** implies a belief that the customer service experience begins once you are on the plane. This isn’t where United’s reputation is created. Once you are on the plane, the customer experience of all of the major airlines is pretty similar.

My experience reflects that it is what happens on the ground that differentiates one airline from another.

Assumptions About Customers Come True

The assumption that customers are just “pissed off at the world” and there is nothing we can do about it is a self-fulfilling prophecy.

If that is the attitude from the top, then it lets the entire system off the hook for making any effort at all to understand the things that might take some of the sharp edges off the experience.

On the other hand, if the attitude is “We are responsible for the experience of our customers – even if we aren’t” then the effort can get focused on understanding exactly what kind of experience we want our customers to have, and engineering a system that delivers it to the best of our ability. That, in turn, allows reflection when we miss, and improvement for the next time.

One is a victim attitude. “We’ll get better customer satisfaction when our customers are better at understanding how hard it is.”

The other is empowering – “Even if our customers *are* pissed off at the world, we will own it and work to understand what we can do.

How Does Your System Respond to Stress?

This in my mind, is what really differentiates a good system from a broken one. Like I said, it’s easy when everything is flowing smoothly. But what happens when the system is disrupted?

Is there a mad scramble of figuring out what to do – like it is the very first time a maintenance issue has caused a flight to be cancelled? What are we going to do with all of these passengers? Process them through two people? (See the line in my photo above!)

Or is there a clear process that gets engaged to get people rebooked – leaving the true difficult cases for the in-person agents?

Ironically, the major airline with one of the very best on-time schedule records also has one of the best recovery processes. Go figure.

Then there are little gestures, like snacks or even pizza for those suffering through a long delay.

“It’s not our fault” easily leads to “you’re on your own.”

“We’re going to own it, even if we don’t” leads to “let’s see if we can help.”

Now… to be clear, the entire airline industry has a long way to go on this stuff. But my point is that some are making the effort, while others have given up.

What Experience Have You Designed for YOUR Customers?

That, ultimately, is the question I am posing here. If you start with the experience you want your customer to have – a standard – then you have a point of comparison.

Did we deliver that experience? If so, then could we do it more efficiently?

If not, what got in our way, how do we close the gap?

Without a standard to strive for, there can be no improvement – and I think this is what Taiichi Ohno actually meant.

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* Estimates of the weight vary quite a bit.

Rough metric equivalents would be around 20 meters long, 9 meters high,  50 tons. About the weight of mid-cold war era tank.

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** With one exception that was booked for me, I haven’t flown on United since mid 2014 after an experience that could not have been better designed to tell the customer “We don’t work as a team or talk to each other.”

I cashed in my frequent flier miles for a camera about a year later.

Lessons from Driving a Forklift

The spring and summer of 2000 were a long time ago, but I learned some lessons during those months that have stayed with me. In fact, the learning from that experience is still happening as I continue to connect it to things I see today.

I was a member of a team working hard to stand up a new production line of a new product. The rate pressures were very high, the production, production control, and quality processes were immature.

At a high level, the parts flow was supposed to work like this:

Steel parts are fabricated and welded, based on the production schedule for various configurations.

Unit sets of parts were sent to outside paint. (We didn’t have our own paint system yet.) In reality, unit sets would be broken up as some parts went to sister plants, others went to outside vendors, each with their own lead times and flow times.

Parts return from outside paint. Because of the different vendors and lead times, different parts arrive on different days.

On assembly day, kits are built for the parts required at each entry point on the assembly line. Those kits are delivered based on a pull. The assembly line had a number of entry points and feeders, so for each takt time cycle, though only one “unit’s worth” of parts were actually delivered, those parts were for different units, as feeders had different lead times into the main line.

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The innocuous challenge was to develop the kitting process (in red) that broke down the parts into  kits and got them delivered to the line.

I got pulled in on Thursday of a “kaizen event” that was supposed to develop this process. What had actually happened, though, was analysis paralysis, a lot of theoretical discussions, a lot of drawings on a white board, but nothing had actually been tested or tried. My assignment was simple: Organize this and get it going on Monday.

I had four people working for me, though they were not officially direct reports. They were an eclectic mix of personalities and styles.

A few things became apparent very quickly:

The process of scheduling which parts needed to be fabricated and welded to be sent through painting on any particular day was broken. Result: What was needed wasn’t necessarily what got sent to paint.

The processes of keeping parts organized during the various outside paint operations was broken. Result: Unit sets got mixed together, parts went missing.

As a result this is what my days looked like:

I came in before a hint of dawn at 4:45am to prepare for the assembly line starting at 5:40. I would go out into the parts yard with the day’s production schedule and a flashlight. My goal was to answer a simple question:

What units on this list can I build with the parts that are here?

I would re-sequence the production schedule to front-load the units that looked like we had everything we needed. (This caused all kinds of problems with serial number sequences and engineering change control, but that is a different story.)

We would start pulling in those parts, and breaking them down into the kits. We set up FIFO lanes for each entry point on the assembly line, and worked as fast as we could to build up about a three hour backlog. Why? Because it took about three hours to expedite a missing part through paint. Once we had that queue built up, as we discovered shortages (or parts painted the wrong color!), we had a chance to get the situation corrected and have a shot at not creating a shortage on the line.

We were working 10 hour shifts, I was typically there for 12-14 hours. Even though I was a “lean guy” my daily work was orchestrating all of this chaos, expediting and delivering parts, and I spent at least six of those hours every day driving a forklift. I got really good at forktruck operation that summer.

At the end of the day, I might sit and chill for a little while, then would get in my truck, go home, and do it all again tomorrow. One of those days as I went to back out of the parking space, I hit the turn signal to put my stick-shift truck into reverse – because that’s how the forklift controls worked.

What I Learned

I actually continue to learn. But here are a few things that have stood out for me.

Shop Floor Production Supervisor is a really hard job. I wasn’t a supervisor, but I was doing many of the things that we asked supervisors to do. Making my people take their breaks. Slow down on the pallet jack. Listening to a frustrated guy who was ready to quit – understanding his paradigm, and helping him re-frame his experience. Constant radio calls to places in whatever building I wasn’t in at the time. Operating within a system that functions only with continuous intervention.

I totally knew how to set up a workable, stable process. I knew how to get all of these processes linked together to pull everything through. I knew how to build in effective quality checks.

What I was able to do was spend a few minutes at the end of my day, or during my lunch breaks (instead of eating) trying to implement some kind of simple visual control that mitigated against repeating a mistake we had just made. We attached a tag with a production sequence number (000 through 999, repeating) to each kit. That let us, and the people on the line, see if we had delivered something out of sequence.

Then, after I had delivered a yellow painted kit to go onto an otherwise blue painted unit (oops) we made a board with the production sequence numbers and the associated colors for the major components.

Then… after I had delivered (note the theme here) the wrong size of a major component to the line, we added that information to the board AND tagged those components so we could quickly distinguish one from the other.

But I was never able to address the upstream issues that were delivering short kits to us in the first place. All I could do was add steps, add time, add inventory to protect myself from those things and do my best to fix it before the main line got stopped.

We had a saying in the Army: “When you are up to your a$$ in alligators, it is hard to work on finding the best way to drain the swamp.”

Thus:

It is unreasonable to expect systems improvements when everyone is scrambling to make the system function at all. It isn’t that they don’t want to make improvements. It isn’t that they don’t know what to do. It is that there is barely time to breathe before the next problem needs to be stamped down.

And finally: A five person job requires five people. I had four people working for me. That wasn’t enough. Guess who had to fill in the rest of it? I tried my best to handle the problems so they could get into some kind of cadence on the stuff that wasn’t a problem. But (Routine+Problems) = (or greater than) 5 people in this case, and it took all of us just to navigate the rapids without dumping everyone out of the boat. If everything was running smoothly, it was probably a three person job. If we could have set up a sequenced pull from assembly all the way back through weld, it would have been a two or even one person job.

Reflection

That forklift key is still on the keyring in my pocket as a reminder of that time. What follows are some of the bigger-picture things that come to mind as I continue to construct, tear down and reconstruct my own thinking.

Attribution Error

There is a strong tendency among us humans to attribute our own failures to a poor environment, but to attribute other’s failings to individual character or capability. Yet in many cases, simply changing the venue or circumstances can allow a previously low-performer to blossom. We see this (and the opposite) all of the time in professional athletics.

Making this error is easy when we are talking about “they.”  If only they… Why don’t they… They don’t get it… “They” are people who are likely doing the very best they can within the context of the system they are in. And, as I pointed out above, changing the system from the inside is hard.

Actually that isn’t quite accurate. Changing the system is hard work.

The Pace of Change

The organization I was describing above was experiencing circumstances at the time that outpaced their ability to experiment, reflect, and adapt. Every organization has a rate at which they are able to change.

Just to make things more complicated, it is possible to learn what must be done much faster than those things can be put into place. This frustrates a lot of change agents. They see the technical changes that must take place, but often struggle against cultural barriers and obstacles. These things take much longer, and it is pretty much impossible to put them on a fixed timeline or project plan. Thus, we frame them as “resistance to change.” We know what must be done, but “they” don’t do it.

Organizations Under Stress

When an organization is under stress, there is fear of complete breakdown. People become very conservative and avoid the uncertain and unfamiliar. If they become overwhelmed just trying to get their task done, they are going to shut out any information that isn’t relevant right now. Horizontal communications break down, and the feeling of isolation increases.

At this point, all coordination has to funnel upward and then downward through the vertical linkages, as cross-functional coordination largely isn’t happening.

Now the higher leader gets overwhelmed, feeling she has to micro-manage every detail- because she does. “Why don’t they talk to each other?” Well, the structures for that were probably very informal, and now have broken down.

This Isn’t About “Them”

As I mentioned above, it is really easy to attribute the perception of dysfunction to individuals. And as people become isolated within their own task-worlds, avoiding a mistake becomes the dominate motivation. This happens even in organizations with the most benign intentions.

If you are a leader, pay attention to the emotions. If people are snippy, are pushing back on ideas as “just more work” then that saturation point may well have been reached. Pushing harder isn’t going to make things go faster, it is going to slow them down.

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…but where is the problem solving?

An external auditor was being shown the wide use of improvement storyboards throughout the organization. He was very impressed by the daily experiments, the documentation of what was being learned, and the results being gained.

Then he said “…but they aren’t doing problem solving.”

Huh? It turns out that, to this person, “problem solving” means using very specific “problem solving tools” such as fishbone charts, Pareto diagrams, histograms, etc. Since he didn’t see those specific tools being used, “they aren’t doing problem solving.”

But they are solving lots of problems – and that was clear.

Another C.I. director had the same complaint: If they aren’t documenting things on an A3 in a specific format, then they aren’t solving problems, or at least aren’t solving them effectively.

People have been solving problems experimentally for thousands of years. There have just been other ways to structure and document the process. I don’t think anyone who has a clue about the process they used could say that Wilbur and Orville Wright were “not doing problem solving” yet there is not a fishbone or Pareto chart in sight. Nope, they just meticulously documented their experiments, their predictions their results, and were laser focused on the problem they were trying to solve.

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Saying people “aren’t doing problem solving” while acknowledging that they are solving problems doesn’t make sense to me, but I have heard it a few times.

Instead of trying to force the creative process through a specific template, how about pulling out the template as a helpful tool when it might help get something unstuck. In other words, for the tool itself – Exactly what problem are you trying to solve?

A Period of Reflection and Learning

Some of you have commented in back-channels that I have been pretty quiet for a while – both here as well as in regular correspondence. I’ve been in pretty heavy reflective mode for quite a while. I described it to someone as “I am learning faster than I can write it down right now – by the time I write something, I understand it in a different way and start over.”

A lot of that reflection has been around consolidating what I learned at from Rich Sheridan, James Goebel and all of the other Menlonians that I have the privilege to know now.

That work was punctuated, though not completed, by my keynote at KataCon last February (2018) where I followed Rich Sheridan and described my interpretation of the underlying meta-patterns that exist in pretty much any organization that we would call exceptionally good at what they do.

At the same time, another client (Thank you, Tomas!) introduced me to Ronald Heifetz and Martin Linsky’s body of work under the umbrella of “Adaptive Leadership.” From their model I think I picked out a fundamental failure mode of what we like to call “change initiatives” regardless of what tool set of operational models we are trying to deploy.

To learn more about this, I read (Note – these are Amazon affiliate links. If you choose to buy the book, I get a (very) small kickback at no cost to you.)

The Practice of Adaptive Leadership

Leadership on the Line

Leadership Can Be Taught

Teaching Leadership

Your Leadership Edge

and every paper and article I could find on the topic or about people’s experience. While doing this, I have tried out many of the teaching and coaching processes as well as applying the observation, interpretation and intervention skills in the course of my work. Those of you who participated in the Experiential Workshop that Craig Stritar and I put on at KataCon early this year were seeing the outcomes of this work up to that point.

My latest step was taking a three day seminar Your Leadership Edge from the Kansas Leadership Center in Wichita the 2nd week of August. The KLC’s model and methods are built on the Adaptive Leadership model. My intended outcome was to consolidate some of my understanding by getting the external perspective and participating within their structure.

The number one frustration of “change agents” out there is some form of “How to I get buy-in?” I know I have experienced that myself. It is easy when all of the constituencies and factions within the organization are well aligned on purpose and values. Not so easy when there are conflicts. I think the Adaptive Leadership model gives us an approach we can learn by practicing. It also mirrors the steps of problem solving / continuous improvement that are outlined in Mike Rother’s Toyota Kata. The context for action is different, but the process is the same: Learning what works through experimentation. That is the “adaptive” part of Adaptive Leadership.

This post is just some background around why I am pursuing this line of thought. As always, I write about things like this to force myself to improve my own understanding by having to explain them in the simplest possible terms. I am happy to have any of you along the journey with me, so subscribe or check-in or whatever and let’s see what we can learn.

Mark